Request for Review of Part B Medicare Claim and Supporting Regulations in 42 CFR 405.807

ICR 200307-0938-007

OMB: 0938-0033

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0033 200307-0938-007
Historical Active 199911-0938-010
HHS/CMS
Request for Review of Part B Medicare Claim and Supporting Regulations in 42 CFR 405.807
Reinstatement without change of a previously approved collection   No
Emergency 08/08/2003
Approved without change 11/18/2003
Retrieve Notice of Action (NOA) 07/25/2003
  Inventory as of this Action Requested Previously Approved
05/31/2004 05/31/2004
6,860,000 0 0
1,715,000 0 0
0 0 0

This form is the preferred manner to enable appellants to request a Part B review by a carrier.

None
None


No

1
IC Title Form No. Form Name
Request for Review of Part B Medicare Claim and Supporting Regulations in 42 CFR 405.807 CMS-1964

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 6,860,000 0 0 6,860,000 0 0
Annual Time Burden (Hours) 1,715,000 0 0 1,715,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/25/2003


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